Health inspection·January 23, 2020

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on record review and interview the facility failed to ensure Advanced Directive were clearly and accurately represented on all resident's charts. This affected two residents (Resident #35 and Resident #42) out of three reviewed for Advanced Directives. The facility census was 51. Findings include: 1. Review of Resident #35 revealed an admission date of 01/07/19 with diagnoses that included dysphasia (difficulty swallowing) and hypertension (high blood pressure). Review of current physician's orders revealed an order dated 01/16/19 for a code status of Do Not Resuscitate-Comfort Care (DNR-CC). This means a person will receive any care that eases pain and suffering, but no resuscitative measures to save or sustain life will be provided. Review of Resident #35's medical chart revealed that the DNR-CC was missing from the advanced directives tab in the resident's chart. Review of the facility policy, Advanced Directives, dated 12/2016, revealed information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. Interview on 01/21/20 at 2:55 P.M. with the Director of Nursing confirmed Resident 35's advanced directive was missing from their medical chart. 2. Review of Resident #42 revealed an admission date of 08/28/18 with diagnoses that included heart failure, Parkinson's disease, and hypertension. Review of Resident #42's January 2020 monthly physician's orders revealed the resident had an order indicating she had a Full Code status. This means the person will receive care and treatment for all health issues and will receive all life saving measures in the event of cardiac or respirator arrest. Review of Resident #42's medical chart revealed an undated DNR-CC form signed by the resident and the resident's physician. Interview on 01/21/20 at 2:50 P.M. Registered Nurse #68 confirmed that the Full code order was incorrect and that the resident's code status was changed to DNR-CC in October 2019. Review of the facility policy, Advanced Directives dated 12/2016, stated copies of guardianship, durable power of attorney and/or living will must be in the resident's chart, and information about whether or not the resident has executed an advanced directive shall be displayed prominently in the Page 1 of 13 366416 366416 01/23/2020 Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953

F 0578 medical record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366416 Page 2 of 13 366416 01/23/2020 Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure two residents remaining in the facility received completed liability notices once skilled Medicare Part A services ended. This affected two residents (Resident #32 and Resident #36) of three residents reviewed for liability notices. The facility's census was 51. Residents Affected - Few Findings include: 1. Review of Resident #32's medical record revealed an admission date of 07/25/19 with diagnoses including Parkinson's disease, high blood pressure, and arthritis. Review of the Notice of Medicare Non-Coverage (NOMNC) revealed the resident's skilled services would end on 09/17/19, and the resident would remain in the facility. It was further revealed that the facility had not completed a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN). Interview on 01/22/20 at 9:15 A.M. with Social Service Director #17 confirmed the facility failed to complete and provide a SNFABN to the resident or her representative. 2. Review of Resident #36's medical record revealed an admission date of 08/29/19 with diagnoses including muscle weakness, high blood pressure, and gout. Review of the Notice of Medicare Non-Coverage (NOMNC) revealed the resident's skilled services would end on 09/25/19 and the resident would resident in the facility. It was further revealed that the facility had not completed a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN). Interview on 01/22/20 at 9:15 A.M. with Social Service Director #17 confirmed the facility failed to complete and provide a SNFABN to the resident or his representative. 366416 Page 3 of 13 366416 01/23/2020 Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #5's medical record revealed an admission date of 06/11/18 with diagnoses including lupus and dementia without behavioral disturbance. Review of the current impaired functional range of motion (ROM) to both upper and lower extremities related to dementia and weakness initiated 08/13/18 revealed staff were to provide assisted active ROM/active ROM to both upper and lower extremities for 15 minutes twice a day. Review of the Quarterly Minimum Data Set (MDS) 3.0 dated 10/22/19 revealed the resident required extensive assistance of two staff members with bed mobility, transfers, dressing and toilet use. The resident required extensive assistance of one staff member with personal hygiene. Further review revealed the resident had functional ROM limitations to both upper and lower extremities. The resident received ROM to both upper and lower extremities daily for the last 30 days. Review of the STNA task documentation from 12/24/19 through 01/22/20 revealed ROM documentation once a day except 12/25/19 and 01/15/20 when the program was provided twice on those dates per the documentation. On 01/21/20 at 2:56 P.M. interview with the Director of Nursing (DON) verified the ROM program was not provided per the plan of care. On 01/21/20 at 3:00 P.M. interview with Licensed Practical Nurse (LPN) #39 verified the program was to be provided twice a day, 15 minutes each time for a total of 30 minutes per day. Based on record review and interview the facility failed to ensure restorative programs were implemented per the resident's plan of care. This affected two (Resident #2 and Resident #5) of three reviewed for range of motion. Findings included: 1. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including chronic pain syndrome, osteoarthritis, acute embolism and thrombosis (blood clots) of superficial veins of left upper extremity, diabetes, cerebral infarction (stroke), and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the right dominant side. Review of Resident #2's current at risk for impaired functional range of motion (ROM) plan of care revealed the resident was at risk for impaired functional ROM related to hemiplegia, hemiparesis, dementia, depression, cerebral infarction and history of deep vein thrombosis to left upper extremity. His interventions included active assist range of motion (AAROM) to left upper extremity and passive range of motion (PROM) to right upper extremity, three sets of 10 repetitions daily for at least 15 minutes a day. Staff were to cue and prompt the resident to perform exercises. Review of Resident #2's ROM documentation located in the electronic medical record under the task tab dated 12/23/19 to 01/21/20 revealed no evidence PROM was performed to the right upper extremity. 366416 Page 4 of 13 366416 01/23/2020 Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/21/20 at 3:23 P.M., with Licensed Practical Nurse (LPN) #39 verified there was no documented evidence Resident #2's restorative program for PROM to the right upper extremity was performed per the resident's plan of care. The LPN reported when she was entering the restorative program into the task tab in the electronic medical record, she must have missed the PROM. Interview on 01/22/20 at 10:02 A.M., with State Tested Nurse's Aide (STNA) #37 revealed the floor staff were responsible for ensuring the restorative programs were implemented. STNA #37 reported she did not know the difference between AROM and PROM. The STNA reported she did not believe Resident #2 was on a restorative program and would have to ask the nurse to find out. The STNA verified she had access to the resident's tasks and plan of care. 366416 Page 5 of 13 366416 01/23/2020 Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to implement fall interventions/physician orders for one (Resident #8) of two residents reviewed for accidents. Findings include: Review of Resident #8's medical record revealed diagnoses including Alzheimer's disease, dementia, vitamin B12 deficiency anemia, insomnia, dizziness and giddiness, and polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain). A care plan initiated 03/11/19 indicated Resident #8 had potential for falls related to Alzheimer's, confusion, and gait/balance problems. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was rarely/never understood and rarely/never understood others. Resident #8 was assessed with short and long term memory problems and moderately impaired cognitive skills for daily decision making. The MDS indicated Resident #8 required limited assistance for transfers and walking in the room and corridor. Resident #8's balance while moving from a seated to standing position, walking and during surface to surface transfer was unsteady with Resident #8 only able to stabilize with staff assistance. On 11/12/19, a physician order was written for dycem (a non-slip material) to the wheelchair to aid in positioning. On 12/06/19, a physician order was written for a pull tab alarm to the wheelchair to alert staff of unassisted ambulation. The order instructed staff to check for the placement and function of the alarm to be monitored every shift. A fall risk evaluation dated 01/21/20 indicated Resident #8 continued to have fall risks including loss of balance while standing. On 01/22/20 at 7:44 A.M., Resident #8 was sitting in a wheelchair in the dining room watching television and conversing with another resident. An alarm box was positioned on the back of the wheelchair with a cord extending toward the seat of the wheelchair. None of the LED indicator lights were lit to indicate it was on and functioning. At 8:55 A.M., Resident #8 was observed propelling herself back to her room leaning forward in the wheelchair. Resident #8 leaned forward, getting items from the bottom drawer of a stand in her room before sitting back. The alarm did not sound. At 9:01 A.M., Resident #8 propelled herself to the nursing station where she stopped to speak. Resident #8 was confused and sometimes struggled for words. The LED indicators of the alarm box remained dark. On 01/22/20 at 9:06 A.M., State Tested Nursing Assistant (STNA) #40 verified the indicator lights on the alarm box should be lit. STNA #40 removed the alarm box from the wheelchair and verified it was in the on position. STNA #40 proceeded to push the clip from the wire into the box and it beeped. The lights lit up. STNA #40 had Resident #8 stand and the pressure alarm sounded. STNA #40 verified Resident #8 did not have a dycem in the wheelchair. On 01/22/20 at 9:47 A.M., the Director of Nursing verified Resident #8 did not have the type of alarm on which was ordered. Resident #8 had a pressure alarm applied instead of the ordered clip alarm. 366416 Page 6 of 13 366416 01/23/2020 Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy reviews the facility failed to ensure Resident #31 was provided an effective pain management regimen. This affected one of three residents reviewed for pain management. Residents Affected - Few Findings include: Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including chronic pain syndrome and paraplegia. Review of Resident #31's pain evaluation dated 12/18/19 revealed he had no pain therefor the rest of the evaluation was not completed (description of pain, what makes pain worse, medications, non-pharmalogical interventions, and if pain medication was effective). Review of Resident #31's comprehensive assessment dated [DATE] to 01/09/20 revealed the resident had no pain. Review of Resident #31's quarterly minimum data set (MDS) assessment dated [DATE] revealed he had pain or hurting in the last five days. The pain/hurting was almost constantly. The assessment indicated the pain did not affect his sleeping or activities of daily living. Review of Resident #31's current chronic pain plan of care revealed the resident had chronic pain related to paraplegia and autonomic dysreflexia (a syndrome with a sudden onset of excessively high blood pressure). The interventions included for staff to assess pain control preferences and attempt to adhere to them, monitor/record pain characteristics, location, onsets, aggravating factors, and relieving factors. Interview on 01/21/20 at 10:19 A.M., with Resident #31 revealed he had constant pain and the Tylenol was not really helping his pain. He said he had reported his concerns to staff. Review of Resident #31's medication administration records dated 12/2019 and 01/2020 revealed the resident had not received the Tylenol. He had physician orders for Tylenol 1,000 milligrams (mg) every eight hours for pain. Interview on 01/22/20 at 9:15 A.M., with Resident #31 and Licensed Practical Nurse (LPN) #24 revealed the resident reported he had pain all over, all the time, especially in his shoulders. He rated the pain a 6-7 out of 10, which was now tolerable for him. The pain at the worst was 9-10 out of 10. The pain scale is zero with no pain and 10 as the worst pain ever. He said the Tylenol was not effective, and he had reported to staff it was not effective, however the doctor did not prescribe anything different, so he just deals with it. The staff or physician have not provided a rational why he could not have anything other than Tylenol. He said he usually doesn't request the Tylenol as it was not effective. The resident reported certain nurses will give him an itching pill and the Tylenol at night. He verified the night nurse gave him Tylenol last night. Interview on 01/22/20 at 10:23 A.M., with LPN #24 verified Resident #31 was admitted to the facility with a diagnosis of chronic pain and his MDS assessment indicated he had constant pain, however his pain assessments and plan of care did not address the resident's location of pain, characteristics, aggravation factors, or relieving factors. 366416 Page 7 of 13 366416 01/23/2020 Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the pain management policy dated 11/2019 revealed all residents shall be evaluated upon admission and at regular intervals for the presence of pain. Residents shall be asked to classify their pain level on a pain assessment scale. Assessment of pain would include location, duration, radiation, and precipitating all alleviating factors. Attempts to control the pain would be employed until the residents reaches acceptable comfortable levels. The physician and responsible party shall be notified of any adverse reactions and the pain management plan shall be revised to better suit the needs of the resident. 366416 Page 8 of 13 366416 01/23/2020 Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview the facility failed to ensure pharmacy recommendations were timely addressed. This affected one resident (Resident #27) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #27's medical record revealed an admission date of 09/17/19 with diagnoses including atrial fibrillation (irregular heartbeat), peripheral vascular disease, hypertensive heart disease and diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and was dependent on staff members for assistance with activities of daily living. The assessment revealed Resident #27 received an anticoagulant for seven days during the assessment period. Lastly, the resident had pain during the assessment period and required the use of as needed pain medication. Review of the physician orders revealed an order for Eliquis (a blood thinner used to treat and prevent blood clots for individuals with a known history of blood clots or atrial fibrillation) 2.5 milligrams (mg) twice a day (ordered on 11/11/19) and Ultram, also known as Tramadol, a narcotic pain reliever, 100 mg every six hours as needed for pain (ordered on 11/14/19). Review of the pharmacy recommendation dated 11/15/19 revealed the resident was taking Eliquis for atrial fibrillation at 2.5 mg twice a day. A dose of 5 mg twice a day is recommended because the resident weighed more than 60 kilograms (the resident weighed 85 kilograms) and had a serum creatinine level of less than 1.5 milligrams per deciliter (the resident's level was 0.94 mg per deciliter). As of 01/20/20, the recommendation had not been addressed. Review of the pharmacy recommendation dated 12/20/19 revealed in patients over [AGE] years of age (the resident was [AGE] years old), the maximum recommended dose of Tramadol is 300 mg per day. The resident had an order for 100 mg every six hours which allowed the resident 400 mg per day. The pharmacist suggested adding a physician order for staff to do not exceed 300 mg per day to the as needed order. As of 01/21/20, the recommendation had not been addressed. On 01/21/20 at 9:56 A.M. interview with the Director of Nursing (DON) verified the recommendation for Eliquis had not been addressed. An additional interview on 01/23/20 at 12:45 P.M. verified the recommendation for Ultram had also not been addressed and placed the resident at risk for receiving more than the daily recommended dose. The DON stated the facility planned to revise their policy and address recommendations more timely when related to medication dosages to prevent residents receiving too much or too little of prescribed medication. Review of the policy for Drug Regimen Review, dated 06/19, revealed any noted/identified medication related issues or concerns will be noted by the pharmacist via drug review recommendations. These recommendations will be made available to the physician in a timely manner and not longer than 60 days from the date of the recommendation. 366416 Page 9 of 13 366416 01/23/2020 Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure Resident #5 was provided routine dental services. This affected one of three residents reviewed for dental services. Residents Affected - Few Findings include: Review of Resident #5's medical record revealed an admission of 06/11/18 with diagnoses including lupus, dementia without behavioral disturbance and hypertension. The resident's current payer source is Medicaid. Review of the dental consent dated 06/11/18 revealed the resident/responsible party consented to emergency and preventative dental services. Review of the plan of care for potential oral/dental health problems related to having her own teeth, initiated 12/12/18, revealed interventions including for staff to coordinate arrangements for dental care as needed and observe/document/report to the medical doctor, as needed, oral/dental problems needing attention such as loose, broken or decayed teeth. Review of the dental assessment dated [DATE] revealed the resident had two to three decayed or broken teeth without pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance from one staff member with personal hygiene. Review of the medical record revealed no evidence of a dental evaluation since admission in 2018. On 01/21/20 at 3:30 P.M., Resident #5 was observed in her room, seated in a wheel chair. A build-up of a white material was observed on the resident's lower teeth, near the gum line. On 01/22/20 at 10:36 A.M., interview with the Director of Nursing verified Resident #5 had been in the facility since June of 2018 and had not received any dental services despite the resident consenting to dental services including preventative and emergency services. The Director of Nursing verified the resident had a white substance on her lower teeth near the gum line and the dental assessment from 10/22/19 indicated the resident had broken or decayed teeth. On 01/22/20 at 1:30 P.M. interview with Social Services Designee #17 verified she was responsible to ensure resident's were seen by the dentist for preventative dental care of they consented for services. Social Services Designee #17 verified Resident #5 had not received any dental services and would be seen by the dentist during the next visit scheduled in February, 2020. 366416 Page 10 of 13 366416 01/23/2020 Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of infection control surveillance logs and interview, the facility failed to complete comprehensive infection control records for infection surveillance, failed to investigate an increase in urinary tract infections, and failed to educate staff regarding infection control practices. This had the potential to affect all 51 residents residing in the facility. Residents Affected - Many Findings include: Review of infection control surveillance logs with Licensed Practical Nurse (LPN) #39 revealed a spike in recorded urinary tract infections(UTI), which developed in the facility, in October 2019. The October 2019 log indicated there were four UTI with catheters and seven non-catheter associated UTIs. However, one of the residents with a catheter associated infection was listed twice, having to be treated a second time. The log indicated three of the residents with recorded UTIs had cultures completed with no results recorded. LPN #39 stated she monitored for occurrence of infections and if/when she noticed a concern it was addressed with the Director of Nursing (DON) and they worked together to provide education for staff. During this interview on 01/21/20 at 5:26 P.M., LPN #39 verified the October 2019 log revealed an increase in the number of UTI. And on 01/21/20 at 6:28 P.M., LPN #39 verified there was no evidence the facility attempted to determine the reason for the increase in UTIs and no education was provided to staff when the increase was noted in October 2019 to try and decrease the infection rate. On 01/22/20 at 5:00 P.M., Registered Nurse (RN) #68 verified determining the root cause of the increases was important in preventing further infections and determining if education was needed and, if so, what type of education. On 01/23/20 at 9:40 A.M., LPN #39 was interviewed regarding the infection surveillance logs not revealing culture results. LPN #39 verified the logs were incomplete although she had the culture results. 366416 Page 11 of 13 366416 01/23/2020 Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm 2. On 01/21/20 starting at 5:26 P.M., infection control logs from July 2019 to January 2020 were reviewed with Licensed Practical Nurse (LPN) #39. LPN #39 was asked to describe the process she utilized in monitoring infections. LPN #39 stated if residents exhibited signs/symptoms of infection the physician was updated and tests were ordered. LPN #39 stated some of the physicians were ordering antibiotics before culture results were obtained and/or ordering antibiotics without obtaining cultures. When this happened, staff asked the physician if he/she was sure they wanted to continue the antibiotic use. LPN #39 stated it was mainly the same two physicians who did this, one being the medical director. When asked if the problem with getting the physicians to comply with the antibiotic stewardship program was discussed with the Director of Nursing (DON) or Administrator to increase compliance, LPN #39 stated she had not discussed the issue with the Administrator. LPN #39 stated every resident who was ordered an antibiotic had an infection report done. When asked what criteria was used in determining if residents had true infections, an immediate response was not provided. Then LPN #39 indicated McGeer's criteria was used. The forms provided did not have sufficient information to determine if the residents met the criteria. Residents Affected - Many On 01/23/20 at 9:17 A.M., LPN #39 stated when physicians gave orders for antibiotics before chest x-ray or culture results were received, she or LPN #24 called the physician and asked if they wanted to discontinue the order. When asked if physicians had been educated regarding the antibiotic stewardship program, LPN #39 stated she assumed the hospital would do that. On 01/23/20 at 9:40 A.M., LPN #39, in the presence of Registered Nurse (RN) #68, was interviewed. LPN #39 provided a copy of an undated letter which RN #68 stated was sent to the physicians in 2017 when the antibiotic stewardship regulations came out informing the physicians of the an antimicrobial stewardship program which addressed the appropriate use of antibiotics, using them only when truly needed and using the right antibiotic for each infection. RN #68 stated she was not aware the physicians were not following the antibiotic stewardship program but had found that a lot of times she just had to remind the doctors or suggest that they needed to wait for results prior to initiating antibiotics. On 01/23/20 at 10:04 A.M., RN #68 stated she and the Administrator just had a teleconference with the medical director and his nurse practitioner and they agreed to be more cognizant about ordering antibiotics without test results. On 01/23/20 at 11:44 A.M., RN #68 verified the antibiotic stewardship policy was vague. Review of the facility's Infection Prevention and Control, Antibiotic Stewardship policy (not dated) indicated nursing would complete criteria checklist as related to symptoms, educate nursing staff on what to monitor if criteria were not met, and continue to inform the physician when criteria was not met of the antibiotic stewardship protocol. The policy did not indicate what criteria was being used to determine if residents had infections or needed antibiotics. On 01/23/20 at 11:44 A.M., RN #68 verified LPN #39 was utilizing the correct form provided by the facility but the form did not provide the criteria in an organized manner to aid in determining if residents met the criteria for antibiotic use. Based on record reviews, interviews, review of infection control/antibiotic stewardship log, and policy review the facility failed to implement a comprehensive antibiotic stewardship program to monitor and prevent unnecessary/inappropriate use of antibiotics. This affected one resident, Resident #32, however it had the potential to affect all 51 residents residing at the facility. 366416 Page 12 of 13 366416 01/23/2020 Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953

F 0881 Findings included: Level of Harm - Minimal harm or potential for actual harm Record review revealed Resident #32 was admitted to facility on 07/25/19 with diagnoses including Parkinson's disease and diabetes. Residents Affected - Many Review of Resident #32's record revealed a fax to the resident's doctor dated 01/07/20 which indicated the resident had complaints of a sore throat and nasal congestion. The physician responded on 01/07/20 and a Z-pak (antibiotic) was ordered. Review of Resident #32's orders and medication administration records (MARs) dated 01/07/20 to 01/11/20 revealed Resident #32 received 500 milligrams (mg) of Z-pak on 01/07/20 and 250 mg on days 01/08/20 through 01/11/20. Review of Resident #32's infection report dated 01/07/20 revealed the resident had congestion, nonproductive cough, and was afebrile (no fever). The resident was ordered a Z-pak. There was no evidence the resident met criteria for antibiotic treatment. Review of the infection control log/antibiotic stewardship log dated 01/2020 revealed no evidence the facility had criteria established to ensure residents met criteria for antibiotic treatment. There was documented evidence if the resident met or did not met criteria. Review of the infection prevention and control: antibiotic stewardship, undated, revealed no evidence what criteria was to be used, however staff was to inform the physician/staff when the criteria were not met. Interview on 01/23/20 at 11:38 A.M. and 11:49 A.M., with Licensed Practical Nurse (LPN) #39 and Registered Nurse (RN) #68 revealed the facility had not been utilizing any criteria to ensure antibiotics were used appropriately. The nurses reported the facility should have been using the McGeer criteria. After reviewing the McGeer criteria with LPN #39 she confirmed Resident #32 would have not met criteria for antibiotic treatment. 366416 Page 13 of 13